THE FOLLOWING FIGURES illustrate estimated payment adjustments based on the established performance threshold of 15 points in 2018 and projected performance thresholds of 78 points in the 2019 and 2020
performance years.

CMS will base Cost performance on the Medicare Spending per
Beneficiary (MSPB) and Total Per Capita Cost ( TPCC) measures.
Each measure will only be used if a case minimum of attributed
patients (35 patients for the MSPB and 20 patients for the TPCC)
can be established for the practice. If this requirement is met for
both measures, the average performance for the two measures
is used to determine the Cost category performance score. If
only one of the two measures meets this requirement, then it is
used alone. If the case minimum requirements cannot be met

18_February.indd 24

for either measure, the Cost category is given a weighting of zero
percent. Under these circumstances the Cost category’s 10 percent weighting is shifted to the Quality performance category,
which would then have a weighting of 60 percent.

Both of these measures factor in risk adjustment when determining Cost category performance. Optimal coding and supporting
documentation will play an increasingly important role in MIPS
performance given that the Cost category’s weighting will reach its
statutory minimum of 30 percent in 2019 and future years. CMS intends to implement multiple new “episode-based” cost measures
in 2019 that will be used to determine Cost performance, again
when case minimums are met for individual providers or, more
likely, groups. Cost performance is determined by claims data and
practices have no reporting requirement for this category.

The weighting of the Quality performance score has been reduced from 60 percent to 50 percent in the 2018 MACRA Rule.
(It will be weighted at 30 percent in 2019.) The Advancing Clinical Information (ACI) performance category weighting remains
at 25 percent and the Improvement Activities performance category weighting remains at 15 percent (see Figure 4 on page 25).
The category weightings change each of the first three years
of the QPP but will stabilize in the 2019 performance year at 30
percent Quality, 30 percent Cost, 25 percent ACI, and 15 percent Improvement Activities (see Figure 5 on page 25). These
weightings are applicable to 2019 and future years, although the
ACI category weighting can be reduced to as low as 15 percent
if CMS determines that an adequate percentage of MIPS clini-

cians are “meaningful users” of Certified EHR Technology.

Quality Performance Category Reporting Period and Criteria
The Quality category performance period is now a full year. In
2017 practices could report for a period as short as 90 days and
still receive the maximum Quality performance score in 2017.
However, the mandatory performance period for the Quality performance category is now 365 days, so quality reporting
started on January 1, 2018. However, practices can implement
their quality strategy after January 1, 2018 as data can be collected retrospectively through most reporting mechanisms (i.e.,
clinical registries, qualified clinical data registries, and EHRs)
with the exception of claims. The claims reporting mechanism
requires that the Quality Data Codes used for reporting quality
measure data be included on the initial claims submission.

Medicare will use claims data for the entire performance year
to determine Cost category performance. The ACI and Improvement Activities performance periods remain at a minimum of 90
continuous days in 2018. The final rule also states that the ACI
performance period will remain at a minimum of 90 continuous
days in 2019.

The data completeness criteria for the Quality performance category has increased. The threshold has gone from 50 percent in 2017
to 60 percent in the 2018 and 2019 performance years. Medicare
intends to increase this threshold in future years of the program.

Practices that submit data through certified clinical registries,
QCDRs, or EHR reporting mechanisms will need to submit data
on 60 percent of all patients that meet the denominator requirements (taking into consideration any potential exclusions or exceptions) for the measures submitted for the entire year, regard-